Financial incentives, such as pay-for-performance (P4P) programs, are increasingly being used to improve physician behavior. However, the impact of these programs on improving quality of care for patients have been mixed, with some studies showing modest gains and others reporting little to no improvement on quality of care measures. Furthermore, unintended consequences of P4P programs have been demonstrated, including larger financial rewards for those hospitals with higher performance at baseline and significant financial losses for hospitals that serve large minority populations. As of October 1, 2008, Medicare will implement the use of a new financial mechanism-nonpayment for preventable complications (NPPC)-which is a "stick" rather than a "carrot". Medicare will no longer pay hospitals for treating certain healthcare associated infections (HAIs) that arise in patients if they are not present on admission. Our proposed research is unique and timely. There are no data available on the impact of a NPPC policy intervention that is being implemented by one of the largest payers in the U.S. Despite lack of evidence for its efficacy, it is hoped that financial disincentives will motivate hospitals and providers to focus their efforts on reducing HAIs. While the goal is certainly worthy, the mechanism being used to motivate change should be rigorously evaluated to ensure that it achieves its intended consequences without the occurrence of unintended consequences. Our research will provide a rich understanding of the potential impact, both positive and negative, of NPPC on patient care and outcomes. The long-term goal of this proposal is to assess the overall impact NPPC on patient care and outcomes. In this two-phase study, we will first conduct qualitative interviews to identify key elements that may affect hospital practices and rates of HAIs. In the second phase, we will develop, pilot, and validate a survey instrument based on our qualitative research findings in order to conduct a future survey of infection preventionists to assess the perceived impact of NPPC on hospitals in the U.S. Thus, we propose the following specific aims: 1. To identify key factors that may affect infection prevention practices in the context of NPPC. 2. To develop, pilot, and validate a survey instrument to examine the perceived impact of NPPC on behaviors and practices in hospitals. PUBLIC HEALTH RELEVANCE: Approximately 1.7 to 2 million healthcare-associated infections (HAIs) and 99,000 deaths due to HAIs occur in U.S. hospitals annually. The economic burden of HAIs is estimated at $17 to $29 billion dollars each year. Our proposed study will provide crucial information regarding the impact of Medicare's use of nonpayment for preventable complications (i.e. reduced reimbursement for hospitalizations associated with HAIs) on quality of care and health outcomes.